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282 Legion Hut Rd � � � , • DAVIE COi3NTY ENVIRONMENTAL HEALTH . • P.O.Box 848/210 Hospital Street �;, • Mocksville,NC 27028 � (336)753-6780/Fax#(336)753-1680 � OPERATION PERMIT � Accc�u�t #: 990005660 '�ax Plf�!EH#: 5736-80-7907-Little Biil�:d Ta: Tresia Little Su�adivisiort I�fo: , Re:ferer�ce N���e: . . LocatianrAd+�r�ss: Legion Hut Road-27028, Pf0�Q5Pt9 F+�CIEI�j�: Residence . � P�c�erty�iz�: 0.979 . � ATC Nu�rtb$r: 5763 **NOTE**The issuance of this.Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G:S.Chapter 130A, Section.1900"Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. � � � � � .� ( 1 Q Q • I � System Type:�S.T.Manufacturer �`���1'!'�11'ank Date �� � T Size 1�Q�v Pump Tank Size / ,� f��� /� 'D ' � � System Installed By: �(7l,t�G�✓� �`e�� E.H.Specialist��l.J✓ �'" Date: � � GPS Coordinate: �� � � � � -` / U� � � Q��v ��• 3 7v � �S� .�2 �—���: ` ,��� � `'� .j,'. •� .0 S u �V v t�+ , � B J y =r . � ... � � ` �� % . c�4 .. � . �� �� �- _'� -� � �"' � � � ' i� � . . (';dc wa� _ ' . � ' y� DCHD 11/06(Revised) � " � � � . DAVIE COLTNTY ENVIRONMENTAL HEALTH ` � �' P.O.Box 848/210 Hospital Street , Mocksville,NC 27028 , ' (336)753-6780/Fax#(336)753-1680 ' ' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Accou�t #: 990005660 - "Tax f�lt�!EH#: 5736-80=7907-Little .. BiEl�t�7a: Tresia Littte . � S��k�iiivisian l�f�: r Refer�nce Nam�: � . .. • .. ° LocalioniAddr�ss: Legion Hut Road-27028 � ' . E�ropos�c9 F�cility: Residence . . . • �ri���rty�Stz�: 0.979 . . . Site Type: B1Vew ❑Repair ❑Expansion ATC Nu�tb�r: 5763 � . � . , **NOTE**T'his Authorization to Construct(ATC)MiJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF�'IVE YEARS. This ATC is subject to revocation if site plans,plat � ori the intended use change. " � . Residential Specifications: #Bedrooms�#Bathrooms � #People � Basement❑ Basement plumbing❑ � Non-Residential Specifications: Facility Type : #People #Seats Square Footage(or Dimensions of Facility) S—� Lot Size . Type of Water Supply: ❑County/City OWell ❑Community Well � System Specifications: Design Wastewater Flow(GPD)�V Tank Size�UGAf..Pump Tank��GAL. s t Q ' Trench Width 3��� Max.Trench Depth 3�P / Rock Depth� Linear Ft.��O C� � � . As s#ated in 15A NCAC :18A.1969(�y�-� �� y � S � .�-� Site Modifications/Conditions/Other: • accepted 5y�tems mav al�� be use � ��- �C�YI �� � Contacf the Davie County Environmental Health Section for final inspection of this system 6etween 8:30—9:30a.m.on the da o ' s allation. Tele hone# 336 751-8760. ,— _ � -� . ��; ' ,� �. �(',u e.,..�.�c� ` _.-- � �--. .t �-- — �- � U , � � ,�,� , _ �i � �, �/�� � � � ` � � t\ � 1z� 3 3 � � � e . }� , ias, � � � � , � � . ;'�' ��' �.�' . o, � � O� �'; ''� � �b . � . � � �o�� �, 4'F �. � �'a - �„ `�,� �f � � �"-'�;��n � Environmental Health Specialist ������ Date: / �� �(� DCHD 11/06(Revised) � � • � . DAVIE COUNTY ENVIRONMENTAL HEALTH • P.O.Box 848/210 Hospital Street , Mocksville,NC 27028 ' ' . (336)753-6780/Fax#(336)753-1680 ' , AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Acc�unt #: 990005660 T�x PiN!EH#: 5736-80-7907-Liftle �.� : • `r 6illesf Ta: Tresia Little _ . .� � Subdivision lnfo: , , . . , .. Refer�nce Nan�e: � '< �: .�.:. � -� : LocationiAddress: Legion Hut Road-27028 ° .. . . _ Propased F�cility: Residence �-`. ,, ; � , -- .`,: �Fro�erty-Srze: 0.979 . Site Type: BNew ❑Repair ❑Expansion ATC �tumber. 5763 .-�--. . . . . , , .. .;, .. , . . � **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental - Health Section prior to issuance of any building permit(s),(in compliance with Artic�e 11 of G.S.Chapter 130A J Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. �' Residential Specifications: #Bedrooms�#Bathrooms � #People � Basement❑ Basement plumbing❑ - Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) S� Lot Size Type of Water Supply: OCounty/City OWell �Community Well � �, System Specifications: Design Wastewater Flow(GPD)�V Tank Size��GAL.Pump Tank��GAL. S Trench Width 3��� Max.Trench Depth 3��� Rock Depth�����!{ Linear Ft.��o l�� � Y`�`-F- As stated in 15A NC�C 18A.1969(� � V � .,-� Site Modifications/Conditions/Other: � accepted Systems mav also be us� , 5 � ��u�-1�C�lil S��-'~� � Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the da o ' s allation. Tele hone# 336 751-8760. r--- _ . ..c � � `Y' cfl(`•v e.�c� � ,_. __—_ 'FA�` .� — U ' (� � � .�. .� � ' � \ � ��' ( ' � � � _ � � (,z� � 3�� . � ° � h � �as. , � . , ' �' �,� ,�.s� . ip� � , � �,, i �b , �' i �. �� o � �' . 4,F `°�.° ��� �'o � ��„ � o�" � ` �a S� � Environmental Health Specialist - Date: "�l�/ ��� DCHD 11/06(Revised) \ � ���� � �� � , . , - . � : � � . � '� � ��` ,r.�.-_ � � . . .� � • • . DAVIE COUNTY ENVIRONMENTAL HEALTH ,� " P.O.Box 848/210 Hospital Street ' , Mocksville,NC 27028 (336)753-6780/F�#(336)753-1680 , AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Acc��r�t #: 990005660 �'�x PINfEH#; 5736-80-7907-Littie Bifle;d Ta: Tresia Little �u�idi�isio►z info: � Referer�ce N���e: LocaiianiAddress: Legion Hut Road-27028 Propas�c� F��:i€ity�: Residence Pro�erty Size: 0.975 �TC [rl�t7ib��': 5763 , Site Type: 8fiew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. �j � Residential Specifications: #Bedrooms � #Bathrooms�#People � Basement0 Basement plumbing❑ � � Non-Residential Specifications: Facility Type #People #Seats � Square Footage(or Dimensions of Facility) . � Lot Size�5 Type of Water Supply: C�County/City ❑Well ❑Community Well � O� �. � System Specifications: Design Wastewater Flow(GPD) ��dI'ank Size �� GAL.Pump Tank GAL. tr . � �— << ^ i . S' Trench Width3li Max,Trench Depth�G Rock Depth �a Linear Ft. o��V f'� Site Modifications/Conditions/Other: •p� stated in 15A NCAC 18A.1969(51 � S accepted Systems may a�u , Contact the Davie County Environmental Health Section for final in5pection of this system between � 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760 l D iky . ._.. ^. -- — 'Y�r'.�.z•--��*-`j '--... � . T— ' . ' � � � -_ \1� � �.�� 3 � � �` h �,,�-- � , ���u �o`�� � �P .. � � �� . � � R ��� 5�,� . �'�� \_ � , .� `3 -- / � Environmental Health Specialist Date: DCHD 11/06(Revised) ; /J 1/`3�� rjv : _ '�, ' � DAVIE COUNTY ENVIRONMENTAL HEALTH . ' � P.O.Box 848/210 Hospital Street ' Mocksville,NC 27028 `. (336)753-6780/Fax#(336)753-1680 ' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Accou�t #: 990005660 �'�x PI�f.��H#: 5736-80-7907-Little Bill��Ta: Tresia Little Su�at�ivi�iart Ir�f�: � Referer�ce Na€�ie: LocaiianiAddr�ss: Legion Hut Road-27028 Pro�asec9 F��;ifity: Residence P�o�er�y Siz�: . 0.975 ATC Nu�'1b�t: 5763 Site Type: C31Vew ❑Repair ❑Expansion **NOTE*.*This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. �+ � Residential Specitications: .#Bedrooms / #Bathrooms�#People � Basement0 Basement plumbing❑ - Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �/ ' �� / Type of Water Supply: �ounty/City �Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) ` �Tank Size��GAL.Pump Tank�/'GAL. 2 (� � l' / � Trench Width /� Max.Trench.Depth �� Rock Depth J��� Linear Ft. L/3G j�f ��s stated in 15A NCAC 18A.15�9(5 ^ "' n ` Site Modifications/Conditions/Other: • aceepted Sy stema mav aly0 b�•uSs?[� d�h � K�d�t GI•'G� -5..s�'-�r'�' Contact the Davie County Environmental Health Section for final inspection of this system between`-� 8:30—9:30a.m.on the da of i t fon. Tele hone# 336 751-8760. . . � \�,� t� . �� Y �� "� . . O _'_ !� �' -� - � � � r'�' '�` �e�y r � � � O � � � ,� � � �. - ` �t0� � , � � _ td��� f �// ��, �l�� _!!� d � �iy `�' � 'o� , , �, � . �j - 7'— // Environmental Health Specialist Date: DCHD 11/06(Revised) ' � � ,� � . . Davie County Environmental Health ' - � ' , P.O.Box 848/210 Hospital Street , Mocksville,NC 27028 • (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005660 Tax PIN/EH#: 5736-80-7907-Little Billed To: Tresia Little Su6division Info: Address: P.O. Box 314 Location/Address: Legion Hut Road-27028 City: Woodleaf Property Size: 0.975 Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with � . Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: CiNew, ❑Repair ❑Expansion Permit Valid for: C�Years ONo Expiration � ���� � Residential Specitications: #Bedrooms / #Bathrooms .3 #People � Basement❑ Basement plumbing❑ � , - ' C Non-Residential Specifications: Facility Type #People #Seats S � Square Footage(or Dimensions of Facility) � Design Flow(GPD): �� Type of Water Supply: �unty/City ❑Well ❑Community Well � As stated in 15A I�CF�C 18s'�.19f9(5� ?O Site Modifications/Permit Conditions: r„ ��, -,.,,� �„a„ �,�,:,�a� �y S stem T e LTAR Initial � Re air Site Plan y�1 ,i� WQ /�V �dI r �V i/ ` �� IQ� i �!Q� lfi� — ^ -10/`�� n------_._ — _ \ = pa�� �r/�y�C y �� � � �� �/�� ,��,�.� � �J a4 ,� : �� b y ti �� No.� pnss �1r-►5� ����.- �o �+��' ��,i'`)G , ' I . ��.n r � � �1'N�(d". . � Environmental Health Specialist' Date �y-� _ // �---r— . i.p.11-06 ,:�.�- , . . '- � ��f�<'� ��� `-�5���� �- , .., � .���� �N �i�� , , � . � ' Davie County Health Department � �,,� � : , ��,�.r - �, ,�j. 4 � Ih �i j� �. � ' . . . . tib t.` �' �;; '� `L `�`L�, ECE��, onrnental Health Section ' ;��t� . r P.O. Box 84$ ; ,� = y� y z�t���� � ��r�E � - � � .�.�J n .� • � � r r+ c : �t J�� `"��� � MAR 2 � 2011 21.0 Hospital St��eet � , � ;,ys;,r�y� - . �.;:�, ;�n � t. � "q ��N�I+�`..l""r C A.. ��.� '�, i�:������- Courier # ; 09-40-06 , �:�f�`> �..�.�:�.� �Y� . Mocksville, NC 27028 �� �:�" � "'-^����'_���"' Phone: (33G)-753-6780 1{ax: (336) -753-1G80 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (CJ,zeck One) eplacement Remodeling Reconnection D �. ✓�Q Name: l ,%G / � PhoneNumber � r�/ U �� e Mailing Address: f �� � -U � -� � : �lS� . . f, , Detailed Directions To Site: �(� � � �� ��� j nl _ t-� D/V �- . Property Address: � • d' �! � � Q Please Fill In The Following Information About The EXISTING Facility: " ""/'"'�� � � �����1� Name System Installed Under: �A � Type Of Facility: Date System Installed(Month/Date/Year): • . Number OfBedrooms: Number Of People: Is The Facility Currently Vacant? Ye No If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility:,...�-�y� ^ Type Of Facility: Number Of Bedrooms: _� � Numbei of People , � Pool Size: ge Size: 02her: ` Requested y, .�� Date Requested: . I� gna� . For Environmental Health Off ce Use Only Approved Disapproved . ; . � / � �, Comments: � � G C l /• � �� �• -, . n /' � � 71i3 i ; Environmental Health Specialist Date: �� — . � *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will fimction properly for any given period of time. Payrnent: Cash Check Money Order # � Amount:$ Date: � Paid By:� Received By: - Account#: ���Q� � Invoice#:�� e��c� �` �� `. �e�;�;f - ?7/9 _ � : • • DAVIE COUNTY HEALTH DEPARTMENT . � . • , , ' � •. � . � Environmental Health Section � • � Soil/Site Evaluation APPLICPaNT INFORMATION PROPERTY INFORMATION Account #: 990005660 � Tax PIN/EH#: 5736-80-7907 Billed To: Tresia Little Subdivision Info: Reference Name: Location/Address: Legion Hut Road-27028� I / Proposed Facility: Residence Property Size: 0.975 : Date Evaluated; � Water Supply: On-Site Well Community Public ✓ ' Evaluation By: Auger Boring Pit Cut ' FACTORS 1 2 3 4 5 6 7 Landscape position Slope% , HORIZON I DEPTH � Texture grou C Consistence �j Structure Mineralo HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence • Structure Mineralo HORIZON IV DEPTH . Texture rou Consistence ' Structure Mineralo SOIL WETNESS ?� RESTRICTIVE HORIZON � SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 0 . ?,� � � SITE CLASSIFICATION: � EVALUATION BY: --�l-- � LONG-TERM ACCEPTANCE RATE: D ' � �� � OTHER(S)PRESENT: 1�!S�4 _ �' �� REMARKS: LEGEND i,andscane Position R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Ternace FP-Flood plain H-Head slope Texture � S -Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt ' SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam ; SC-Sandy clay SIC-Silty clay C-Clay . ' ' � ' �ONSISTENGF. � . lYIQ1St VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic . Str�cture SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky , SBK-Subangular blocky PL-Platy PR-Prismatic lyjineraloav 1:1,2:1,Mixed . L�Iotes Horizon depth-In inches � Depth of fill-In inches , Restrictive horizon-Thickness and inches from land surface • Saprolite-S(suitable),U(unsuitable) � Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable);U(unsuitable) TTAR -T.nnv_tPrm arrPnfanrP ratr_ aal/�lav/ft� r�nTrn ncmc in__.___�� 1VIap Frame , Page 1 of 1 . , , • . . ' ' - - Davie County, NC - GIS/Mapping System oQ!sV��c` �+' J-:� � �,�_ W • Click Flere Ta Start �uer �, `�� � �� vJ °�`� Quick Search:�CountY ID or Oti�aner N< o U��C � ?: Active Layer. �Use htap Tr,�s � :�' �` � (�PARCELS (Map Tips Available) � � Ma 1 _----- __ _ -�`-- ---- - -� Ad d re �M50000000104 4.68 AC LEGION NUT RD I�"~-.�����- ��,s� ,/ �,�; —�----� _� � � � ��� ; �--� �-� .� . .._ :._ , � . �y Nu� �0 '� 1�'`� ! Z;�; ; ��.���r r ` ! z��3 r :;� r .�' 1 ,,,;� � !. � � �� � �J�� �v� � Do$O(t � �� � � �� � . e� �, � � � http://maps.co.davie.nc.us/GoMaps/map/mapframe.cfm?CFID=4129&CFTOKEN=616408... 3/29/2011 .� DAVIE COUNTY HEALTH DEPARTMENT . (� 3- 3 0-°� . ' � , � • • � • ' . Environmental Health Section ' ' �• ' P.O.Boa 848/210 Hospital Street . •:-'�-• -� Mceksville,NC 27028 • (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002524 Tax PIN/EH#: 5736-80-99366V Billed To: Beatrice Vaughters Subdivision Info: - Reference Name: Location/Address: Legion Hut Road-27014 Proposed Facility: Residence Property Size: see map ATC Number: 3345 **NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWAT'ER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People�_ #Bedrooms� #Baths�_ Dishwasher:� Garbage Disposal: ❑ Washing Machine;,� Basement w/Plumbing: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type � #People #People/Shift #Seats Industrial Waste: � Lot Size /�/�'C' Type Water Supply� Design Wastewater Flow(GPD) 7 �6 Site: New�Repair❑ System Specifications: Tank Siz%/ GAL. Pump Tank GAL. Trench Width���Rock Depth,�_/Linear Ftt,��v! Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** � � ���� / r-- _" Env�ronmental Health Spec�ahst s Signature: �� Date: / 9 � � DCI-ID OS/99(Revised) ' � � -. � • � DAVIE COUNTY HEALTH DEPARTMENT . , . . . . Environmentai Health Section . P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990002524 Tax PIN/EH#: 5736-80-9936BV Billed To: Beatrice Vaughters Subdivision Info: Reference Name: Location/Address: Legion Hut Road-27014 Proposed Facility: Residence Property Size: see map ATC Number: 3345 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: /`�,��/ Date:��"'"L— � CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovementlOperation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCI-ID OS/99(Revised) • �'r . - ' �� � Q� � � � . � ' � � � • `' • �' � .�_ APPUCATION FOR SITE EVALUATiON/IMPROVEMENT PERMIT&AT 0 G� � �j� Davie County Health Department �" � /� �� � � ��. �s` C� � � Environmenta/Hea/thSection �' 3 ��� � P.O, Box 848/210 Hospital Street � Z , 0 Mocksville, NC 27028 FN�/R�� �` 1 � (336)751-8760 �•^j�F�1Tq � ,� ���UN yfq(T ***IMPORTANT*** THIS APPLICATION CANNOT EE PROCESSED UNt,ESS ALL THE REQUIRED INFORt�TION IS PROVIDED. Refer to the INFORL�ATION BULLETIN for instructions. � 1. Name to be Billed 1 Q Contact Person Mailinq Address 1 Home Phone ���(p '��lj 7'� (�U� / City/3tate/ZIP ��i�n�ee rhee , /V.l.� �/V /7 Business Phone ' 2. Name on Permit/ATC if Different than Above � �I� � Mailing Address � T� �"� City/State/Zip ��i�1 � 3. Application Eor: ❑ Site Evaluation p Improvement Permit/ATC �th a. syatem to service: ❑ House �obile Home ❑ Business ❑ Industry ❑ Other s. �f Residence: p People �_ # Bedrooms � # Bathrooms � Dishmasher ❑ Garbaqe Disposal Washing Machine O Basement/Plumbing ❑ Basement/No Plumbing ,: 6. If Business/Industry/Others Specify type Y People # sinks k Commodes �i Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gaiions per day) 7. Z�pe of water supply: County/City � Well ❑ Community s: Do you anticipate additions or expansions of the facility this system is intended to serve? �Yes �-Ai'� If yes,what type? ***IMPORTANT*'�*CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eit6er a PLAT or S1TE PLAN MUST BE SUBMI7TED by the client with THIS APPLICATION. Properly Dimeasions: � f'�'��� S' WRITE DIRECTIONS(from Mocksville)to PROPERTY: /' / �/� (y V Tax Oftice PIN: #��`� k) L�q -1���� � . r J Property Address: Road Name--� !.�'� �il � � � �City/Zip__���'F'- �P `u � � n lf in a Subdivision provide infor ation,us fol o s: �T f' � Name: � llI GJ /l� /� �GU����l�� U b � � �rar� ���i�d e�o�"� ous�L/ Section: Blcek: Lot: D tc �rty Flagged: e. ' e. �OuP'� ���o ,� r�.a�t.� This is to certify that the information provided is correct to the best of roy knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I am responsible for all c/rarges inc�irred from this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. � �,. DATE �/ /1�/f�. 3-' �',2 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of thc following: E isting and proposed property lines and dimensions, structures, setbacks, and septic locations). (� ' ���� 3 v �«, � ceivt�,;.:� Site Revisit Charge / ( o�.�,- _ Date(s): � �( � � � `� J � � > Client Notification Date: - l v �b(/- ��'�_ L�,�(1 Z � EHS• ('� � `( v � � Account No. ���� C�--�- �- � ��--5-�� �l � .� Rev�sed DCHD(07/99) � _ . 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Slo e% Ct HORIZON I DEPTH �� — Texture rou G Consistence � Structure t�. Mineralo t� HORIZON II DEPTH � �/' yD�� ' Texture rou • Consistence i Structure 6 a2 Mineralo % � HORIZON III DEPTH Texture rou Consistence ' Structure Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE - •�7 SITE CLASSIFICATION: "J EVALUATION BY: LONG-TERM ACCEPTANCE RATE: " � OTHER(S)PRESENT: REMARKS: LEGEND � Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silry loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) _ LTAR-Long-term acceptance rate-gal/day/ft2 DC�ID OS/99(Revised) ` ■■�����e■■���■�■����■��■��■�■e■�e■■�■�■����■��■■■�■�■■�■��■ ����■ ■���t�������■■������■�����■������o■����■��■�����■�■����a�����■�■�■ ■�■����������■�����■■■��■�■��■�■��■�■����a■�■�����■���������■��■■ ■■�����■��■����������■■�■��■���■ ■�����■���■s���■�■■s�����������■ ■�■����■■�■■���■�■�■��■�■■����������■�■��■������s■��■�■�������■��■ ■��������■�■��������■��e�■����■�■���■�■��■������������■��■��■■���■ ■�����■��������■■�■�■�e■��■��■���■�����■�■���■�o■��������■��■��■�■ 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F�1d R0 7 i� n�t� nqu(nnwnt� ior noo�inq. n f Nothon L Tyson �n,. � �•r .r.,._._...�_. �.o. �• • R6 717 O PG 749 //'�J','`/ an/d Fraae�s A. Y«x�g �. �r.,�r sn.d. Rql�t�r .r o..a sR �i2a ;l--� s�o I or S t a + PB a • PG 59 �� � L / DB 138 O PG 6sa F 1 I 1�� F . e�� 2 . �ot t-�+:�+f-�ot 2 ^p George R. Stone R e f: D B t d 9 O P G 7 0 7 for �---- �� ��o s�.�i�3�sz s�� to�" �ot�i°�' � .,....... , �/ �h+o �n er cou�mr at.�r�nc oeP� � �cno�s rtevisea Tax l.oc 1.as o�.�, 20��0{�F,$$/0��/, R�Olstrstl�n Nwi�r 1 a 5�1�. 7 recto► � : L-3162 �w / �� �'•�y �:�2 ��t� , r � �� �_ •...--- -" mae�ten.Rd . C•°,sU ••'y� , j� �!- �r"' Port of Tax Lot 1. Tax blap M-5 ��t zs sR t�2t � F ROBER'( Tr�F w�� —2 � __.... _ Vicini�Y MoP (Mot �o Scale) w i� �RRS 8erd/Fnd 4�v�Ibb.rt lhen..Piel.�lwwt t.ana swv�yer.�-Ste=.aA�Y b eM f l� i 1 � a m.ro�e.�o.wwieow u�.. � « �: i ' � � (w) hw�by o�rtMy tl+dt� an (w�are) tl+�orrnw(�) � a. lhot tli v�M�f e wnv�tAst aMr.sMwMMsn d 1wd wMli� / � 1M a�a d e aw�r a nwmldpalyr tlMR As a�adnaa�1hd Tax LOt 1.04 d!M propwty dMorlD�d h�ron� trNeh b locat�d In Tax M-S RRS Fnd • Cl ot SR 1123 / � Tax Lnt 1.02 tM subdl�fNo� o/ povb CouMy and thot �v�+d w� n/f C�I�o Pruitt Control Comer � ; Tox Mop (d-S 1 ►+Krby adop�t lMs subdNt�fon pion �Ilh my hw � e. nr�w.�ac r�e..�aw r rew.s�.�en o�a e ond L�o Prultt n�f L.indsay Conrod Smoot au�y a nwreasiq�uet tr u�,�se�e e.es an ad�nenee R8 371 O PG 621 __ and Sharofl Oenhe Smoot oo�+t.�stoWhhed n�Ininwm M�Nsnq Mlbadt N►�t u�►.��w.aw�o.r a w�a� and d�dlead aM strwts. dM'!nh weM�s. PaACs and / �'—c�o�orlw DB 201 O PG 889 � 4 ��ae r.r e.�w.y a.�w.�p�..r•a•�• � F.no�` � Ref: PB 7 • PG 22 for athK �and�o�t�+t�to puMb or priwes tw� � a n.c w.�w w.....r a■ww.r..�.�r..w�.N. � / /��� � �� SR�Qs 1123tto Ta��tot 1.2m a� �ct�d. , � , * n�n�ntlon e�.A�q pae�,,.oewe-as�ne.nv.y or aM. � / � � Across Rwls�d Tox Lot 1.OS } '0 d�s -Og �epllen es IM aMhitlsn at MrbArwar, ��, / /� � � � w n,.t a.MMwn�.rieW.r Mr..wnye►Y.ra,+Mc�.n I .' � o W � O U i 1 p r�AN b niM o d�Irnb�aYa�b b�b�!d��relr/oeel • / � �i �1 r � � � ��� � � O aeMy n.b�w e�eMwd tn l���(�� g / � �� i �� t.. 4 y- Q,o l�` � �(a � �� / �•�, �"� � � � ��N a / � 23- y 0�3 George R. Sto�e �w sw��«�a �_ /dt� � � � �� � i �, � L 4 � r-- L S � � � '�,, � oen an«t�) O Q . . � / s Recombination su ot axistin rcels. ��� � ` -- �Y 9 Po �' O k�� / cro....tAt �.os ' � `. , r '_ __ --;� OM►n�n: } / � � , Buildiny A� shsd crosee. Ethsl Louise Pruftt �V �L '1 } I , , � __, -- Prop�rly Ltns _- -'' � 26� Lpion Hut Rood � �y1 �fi 5�'�O ' �� I i I " 1� ► ' �.�`' �' -- Growt Dri ~ �I �$ Mocksvill�. N.C. 27�28 �♦ Q�I ,�e ��J' / � ,,, � � � --------v_" -'' �j • +'� �� , 6 � `� � " - - - - �� Jonathan A. Vauql�te►s �Q/v`P 53 ♦ Tox Lot 5 i � � - - - �/2 pR Fnd • Q �9�'i� / Tex Map M-S � %F.,,�.-�,,�. c,�avd-e► �� Oeshauna Vaughten t ' i ���a.e� so� �... e�»„� �.o. eox tat Ye�' `� a � / o�'a4 i PG�3�o9 D� �i� �` �d`R � � Pe e • Pc ao. Moc�avt�k. N.c. 27029 \ � .-. / J � . �t RB 746 � PG 20C / / � .�•� � � + "� `�` � Revised � i f �s cc +o.r � � � / � + -" � Tax Lot 1.06 / � / �' Tax Map M-5 � ° � / / Fencs / � � � • 1.037 Acres +/- / Tax Lat t � ��� �� Tax IAop M-5 � /� Revised wkhin SR 1123 R/iM � �� J• ��E� o ( Tax Lot 1.05 �` Di1c �'O"'r R�'�' Katie R. hlcDonisl �I�� � ���/4�� E!P Fnd Tax Map M-5 �� f Rg 745 • PG 28� i � ° ° 1 0.979 Acrea +/- / RRS Fnd 0 Cl of SR 1123 � TOx LAt d -- Inciwiw d Ma � �,� 4�J� � q./ CL of Crosk (ReI: PB 7 PG 22) T� �P �-� � within SR 1123 R/W �! i C• / _�1 ,� Contrd Com�r n/f Kevin Stockton J �c� � � � . �/ Ac Shamiloo Porney w , ° �� �p J � � � �� RB 657 O PG 503 ,J ao � a` ,�� �t�'/ /. '_. I / ��e� 4� I f �---_� J �/ / o �j Nai! Fnd O 8ent TM V�� 3/4" QP Fnd NOTZEoSn� R/A Car Jack Fnd O 5ton� :=1� ry�1 g t�.-9 � �=8 g N 68•�13'19"W 2. Minimum 9uildiny Setback Un�s: � 44�•52� / Front: 40'� Rear. 30', 5de: 15' ��' °� a o � , 3. Watershed Classification: WS-N - - d� 4. No t1SGS or NCCf�SS Yonumeryts tound within 2000' of sits. �� � � � / 1 S. /JI lots sholl b� wrwd b�r public watar per owner. �• � ^ ��'� Ta �M-s ° Recombtinattio�n Suruey far: . R,� _ �,t�,_ � � - ��.�,�„� / � �!�,�P�°^ E the t L ou2se P�r,czt t oP-�w� �. eoc -e�a cu� � � Re aS7 • Pc 5�03 / � � ��'� �� �_�Po�" ° Jonathan A . Vcxughters, cw -ca,�.�,,.,e M►+ - ��. / ��� - "�°R�`� �'- `�°'�°'�°�°' & Deshauna Vacughters P/L- Propaly iln� P/O - Part d / CP�-co�P1p�i� P�B- Pl�ot eook PROPERTY UNE CAtl TABLE � -�OR"�� � - �0°'�aOO�` � Tax Lot 1.05� Tax Mcp M-5, cPv_co�c.a Pb.ck v� Pc- P COURSE BEJIRING DISTAt�E -F- 10�Y�or Ftood 8oundary ce-ca�i,eo.�, Record Book 717 O Pags 749 -o- ov�rlraa utlflW. -s- sw�r un. -x- F«,o. ww -woa►►�aK L-1 N 3a•33'20"E 76.06' Tcx Lot 1.06, Tox Map M-5, f"d -�°'"'d wv-�►°e"r°N' L-2 S 67'37'48"E 29.95' Daed Book 200 Page 388 n/r- Mow or iam«4y eM - B�ncn Mor+c ►� -no„r�w„�c.d Potnc � -r«� sw,a�, wm+� L-3 S 21'34'45"Ir 177.85' Referonce Plat Book 8 • Page 59 a- c.�un. aRs - r��s�r. �-4 S ad'07'37"E 32.32' Total /kec: 2.016 Acres +/- by coordinate geometry �-�.a Pawm.nt crv- tbet.T.i.v�.lo�P.e..tai L-5 S 68'07'37"E 185.18' TP -TM�phon�P�d�atd EI9-ENe4rte Tron�forn+K Box � I � -w-w�e.r un. co-so�kay swr.r ci.on a,t L-6 S 21•51'46"W 50.�' Incivaive of Area within SR 1123 R W � Duke Power R L-7 5 56•33'2Q"W 292.52' � � � �� � L-8 N 68'12'S5"W 21.61' 1" e BO' Jeruaalem Davls North Cvrolino 7-29-2008 L-9 N 66•12'S5"W 73.56• 60 0 60 120 180 �—�o � se�24�o9��r �t�.�s� ' , „ , ��; Stone l.and Survey�ng ompany ,,oe„o, 1-11 N 36'3516 E 124.92 ��R L-12 N 36•38'Ot"E 287.17' IiAT,De.RS u�a�Robwt�ter� p�s�-3terl GRAPHIC SCHLE - FE� L-13 N 00�40'37"E 205.44' MAPPED: 151-B SoutA Moin St (336) 998-4733 � �' L-14 N 57'27'15"E 125.38' G� Mockavi�b. 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